Joints and Joint Procedures – Medicare Advantage Coverage

Home , Arthroplasty, Arthroscopic lavage, Hip replacement, Hip resurfacing, Joint replacement, Shoulder replacement

UnitedHealthcare® Medicare Advantage Coverage Summary Joints and Joint Procedures

Policy Number: MCS052.02 Approval Date: July 20, 2021  Instructions for Use

Coverage Guidelines ...... 1 Related Medicare Advantage Policy Guideline • Core Decompression for Avascular Necrosis...... 1 • Arthroscopic Lavage and Arthroscopic Debridement • Hip Resurfacing ...... 2 for the Osteoarthritic Knee (NCD 150.9) • Hip Replacement Surgery ...... 2 • Hip Acetabuloplasty ...... 2 • Knee Replacement Surgery ...... 3 • Arthroscopic Lavage and Debridement for Osteoarthritis of the Knee ...... 3 • Unicompartmental Knee Arthroplasty ...... 3 • Elbow Replacement Surgery ...... 3 • Shoulder Replacement Surgery ...... 3 Supporting Information ...... 4 Policy History/Revision Information ...... 4 Instructions for Use ...... 5

Coverage Guidelines

Hip and knee procedures may be covered when Medicare coverage criteria are met.

Core Decompression for Avascular Necrosis Core Decompression of Femoral Head (CPT Codes 27299 and S2325) Medicare does not have a National Coverage Determination (NCD) for core decompression for avascular necrosis. Local Coverage Determinations (LCDs/Local Coverage Articles (LCAs) do not exist at this time.

For coverage guidelines, refer to the UnitedHealthcare Commercial Medical Policy titled Core Decompression for Avascular Necrosis. Note: After searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

Core Decompression Other Than Femoral Head (CPT Codes 21299, 23929, 27599 and 27899) Medicare does not have an NCD for core decompression for avascular necrosis. Local Coverage Determinations (LCDs/Local Coverage Articles (LCAs) do not exist at this time.

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Hip Resurfacing (CPT Code 27130) Medicare does not have an NCD for hip resurfacing. Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) exist and compliance with these policies is required where applicable. For specific LCDs/LCAs, refer to the table for Hip Replacement Surgery (Arthroplasty).

For coverage guidelines for states/territories with no LCDs/LCAs, refer to the UnitedHealthcare Commercial Medical Policy titled Surgery of the Hip. Note: After checking the Hip Replacement Surgery (Arthroplasty) table and searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

Hip Replacement Surgery (Arthroplasty) CPT Codes 27130, 27132, 27134, 27137 and 27138 Medicare does not have an NCD for hip replacement surgery (arthroplasty) (CPT codes 27130, 27132, 27134, 27137 and 27138). Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) exist and compliance with these policies is required where applicable. For specific LCDs/LCAs, refer to the table for Hip Replacement Surgery (Arthroplasty). For coverage guidelines for states/territories with no LCDs/LCAs, refer to the UnitedHealthcare Commercial Medical Policy titled Surgery of the Hip. Note: After checking the Hip Replacement Surgery (Arthroplasty) table and searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

CPT Code 27125 Medicare does not have an NCD for hip replacement surgery (arthroplasty) (CPT code 27125) Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) do not exist at this time.

For coverage guidelines for states/territories with no LCDs/LCAs, refer to the UnitedHealthcare Commercial Medical Policy titled Surgery of the Hip.

Notes: After searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

Hip Acetabuloplasty (CPT code 27120 and 27122) Medicare does not have an NCD for hip acetabuloplasty (CPT codes 27120 and 27122). Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) do not exist at this time.

For coverage guidelines for states/territories with no LCDs/LCAs, refer to the refer to the UnitedHealthcare Commercial Medical Policy titled Surgery of the Hip. Note: After searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

Surgical Treatment for Femoroacetabular Impingement (FAI) Syndrome (CPT code 29914, 29915 and 29916) Medicare does not have an NCD for the surgical treatment for of femoroacetabular impingement (FAI) syndrome. Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) do not exist at this time.

For coverage guidelines, refer to the UnitedHealthcare Commercial Medical Policy titled Surgery of the Hip. Note: After searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

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Knee Replacement Surgery (Arthroplasty) (CPT codes 27445, 27447, 27486 and 27487) Medicare does not have an NCD for knee replacement surgery (arthroplasty). Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) exist and compliance with these policies is required where applicable. For specific LCDs/LCAs, refer to the table for Knee Replacement Surgery (Arthroplasty).

For coverage guidelines for states/territories with no LCDs/LCAs, refer to the UnitedHealthcare Commercial Medical Policy titled Surgery of the Knee with individual consideration for the following: Avascular necrosis of the knee Proximal tibia fracture

Note: After checking the Knee Replacement Surgery (Arthroplasty) table and searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

Arthroscopic Lavage and Debridement for Osteoarthritis of the Knee Arthroscopic lavage and debridement for osteoarthritis of the knee are not covered; neither is lavage alone or debridement alone for osteoarthritis.

Arthroscopic lavage and or debridement of the knee for patients without osteoarthritis who present with symptoms other than pain alone (i.e., mechanical symptoms including but not limited to, locking, popping and snapping, limb and joint alignment, less severe and/or early degenerative arthritis) are left to the discretion of the Medical Director based on case review of documentation. Refer to the NCD for Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee (150.9). (Accessed July 14, 2021)

For guidelines for Open Osteochondral Autograft, talus (CPT code 28446); Autologous Chondrocyte Transplantation in the Knee (CPT Code 27412); and Osteochondral Grafting of Knee (CPT Codes 29866, 29867, 27415 and 27416), refer to the Coverage Summary titled Orthopedic Procedures, Devices and Products.

Unicompartmental Knee Arthroplasty (CPT code 27446) Medicare does not have an NCD for unicompartmental knee arthroplasty. Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) do not exist at this time.

For coverage guidelines, refer to the UnitedHealthcare Commercial Medical Policy titled Surgery of the Knee. Note: After searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

Elbow Replacement Surgery (Arthroplasty) (CPT codes 24360, 24361, 24362, 24363, 24370 and 24371) Medicare does not have an NCD for elbow replacement surgery (arthroplasty). Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) do not exist at this time.

For coverage guidelines, refer to the UnitedHealthcare Commercial Medical Policy titled Surgery of the Elbow.

Note: After searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

Shoulder Replacement Surgery (Arthroplasty) (CPT codes 23470, 23472, 23473 and 23474) Medicare does not have an NCD for shoulder replacement surgery (arthroplasty). Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) do not exist at this time.

For coverage guidelines, refer to the UnitedHealthcare Commercial Medical Policy titled Surgery of the Shoulder.

Note: After searching the Medicare Coverage Database, if no LCD/LCA is found, then use the policy referenced above for coverage guidelines.

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Supporting Information

Important Note: When searching the Medicare Coverage Database, if no LCD/LCA is found, then use the applicable referenced default policy below for coverage guidelines.

Hip Replacement Surgery (Arthroplasty) Accessed August 23, 2021 LCD/LCA ID LCD/LCA Title Contractor Type Contractor Name Applicable States/Territories L33618 Major Joint Part A and B MAC First Coast Service FL, PR, VI (A57765) Replacement (Hip and Options, Inc. Knee) L36039 Total Joint Arthroplasty Part A and B MAC National Government CT, IL, MA, ME, MN, NH, NY, (A57428) Services, Inc. RI, VT, WI L34163 Total Hip Arthroplasty Part A and B MAC Noridian Healthcare AS, CA, GU, HI, MP, NV (A57683) Solutions, LLC L36573 Total Hip Arthroplasty Part A and B MAC Noridian Healthcare AK, AZ, ID, MT, ND, OR, SD, (A57684) Solutions, LLC UT, WA, WY L36007 Lower Extremity Major Part A and B MAC Novitas Solutions, Inc. AR, CO, DC, DE, LA, MD, MS, (A56796) Joint Replacement (Hip NJ, NM, OK, PA, TX and Knee) L33456 Total Joint Arthroplasty Part A and B MAC Palmetto GBA AL, GA, NC, SC, TN, VA, WV (A56777)

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Knee Replacement Surgery (Arthroplasty) Accessed August 23, 2021 LCD/LCA ID LCD/LCA Title Contractor Type Contractor Name Applicable States/Territories L33618 Major Joint Part A and B MAC First Coast Service FL, PR, VI (A57765) Replacement (Hip and Options, Inc. Knee) L36039 Total Joint Arthroplasty Part A and B MAC National Government CT, IL, MA, ME, MN, NH, NY, (A57428) Services, Inc. RI, VT, WI L36575 Total Knee Arthroplasty Part A and B MAC Noridian Healthcare AS, CA, GU, HI, MP, NV (A57685) Solutions, LLC L36577 Total Knee Arthroplasty Part A and B MAC Noridian Healthcare AK, AZ, ID, MT, ND, OR, SD, (A57686) Solutions, LLC UT, WA, WY L36007 Lower Extremity Major Part A and B MAC Novitas Solutions, Inc. AR, CO, DC, DE, LA, MD, MS, (A56796) Joint Replacement (Hip NJ, NM, OK, PA, TX and Knee) L33456 Total Joint Arthroplasty Part A and B MAC Palmetto GBA AL, GA, NC, SC, TN, VA, WV (A56777)

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Policy History/Revision Information

Date Summary of Changes 07/20/2021 Routine review; no change to coverage guidelines Archived previous policy version MCS052.01

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Instructions for Use

This information is being distributed to you for personal reference. The information belongs to UnitedHealthcare and unauthorized copying, use, and distribution are prohibited. This information is intended to serve only as a general reference resource and is not intended to address every aspect of a clinical situation. Physicians and patients should not rely on this information in making health care decisions. Physicians and patients must exercise their independent clinical discretion and judgment in determining care. Each benefit plan contains its own specific provisions for coverage, limitations, and exclusions as stated in the Member’s Evidence of Coverage (EOC)/Summary of Benefits (SB). If there is a discrepancy between this policy and the member’s EOC/SB, the member’s EOC/SB provision will govern. The information contained in this document is believed to be current as of the date noted.

The benefit information in this Coverage Summary is based on existing national coverage policy; however, Local Coverage Determinations (LCDs) may exist and compliance with these policies are required where applicable.

There are instances where this document may direct readers to a UnitedHealthcare Commercial Medical Policy, Medical Benefit Drug Policy, and/or Coverage Determination Guideline (CDG). In the absence of a Medicare National Coverage Determination (NCD), Local Coverage Determination (LCD), or other Medicare coverage guidance, CMS allows a Medicare Advantage Organization (MAO) to create its own coverage determinations, using objective evidence-based rationale relying on authoritative evidence (Medicare IOM Pub. No. 100-16, Ch. 4, §90.5).

CPT® is a registered trademark of the American Medical Association.

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